Provider Demographics
NPI:1942720826
Name:SULLIVAN, STEPHANIE THERESA (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:THERESA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:T
Other - Last Name:ENSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 JOANNA DR
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01543-1245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:177 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:MA
Practice Address - Zip Code:01562-1711
Practice Address - Country:US
Practice Address - Phone:508-885-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3022152W00000X
MA5686152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist